Gene F. Kwan

Cardiac Rehabilitation 2012 Advancing the Field Through Emerging Science

Burgeoning research in the field of preventive cardiology over the past 20 years has fostered the evolution of cardiac rehabilitation programs, once limited to exercise training, into comprehensive secondary prevention centers. Data demonstrate that contemporary cardiac rehabilitation/secondary prevention (CR/SP) programs reduce cardiovascular risk and event rates, foster healthy behaviors, and promote active lifestyles.1,2 Accordingly, every recent major evidence-based guideline from the American Heart Association (AHA) and the American College of Cardiology Foundation regarding the management and prevention of coronary heart disease provides a class 1 level recommendation (ie, procedure/treatment should be performed/administered) for referral to a CR/SP program3,4 for those patients with recent myocardial infarction (MI) or acute coronary syndrome, chronic stable angina, or heart failure, or for those patients following coronary artery bypass surgery or percutaneous coronary intervention. CR/SP programs are also indicated for those patients following valve surgery or cardiac transplantation.3 Emerging science will undoubtedly advance the field further, as clinicians translate data to foster future change. In this brief review, we provide a focused update on recently published studies that have great potential to move the field of cardiac rehabilitation forward. These studies address the following topic areas: utilization of CR/SP services and associated survival benefits; novel exercise protocols; and emerging applications in the management of diabetes mellitus, heart failure, pulmonary hypertension, peripheral arterial disease, and congenital heart disease. Despite the wealth of evidence supporting the proven benefits of CR/SP programs, the services are greatly underutilized. Of eligible patients, only 14% to 35% of heart attack survivors and 31% of patients after coronary artery bypass surgery participate in CR/SP programs.5,6 To reduce the gap between indication and implementation, a joint American Association of Cardiovascular and Pulmonary Rehabilitation/American College of Cardiology Foundation/AHA committee has recently revised the performance …

Endemic Cardiovascular Diseases of the Poorest Billion.

The poorest billion people are distributed throughout the world, though most are concentrated in rural sub-Saharan Africa and South Asia. Cardiovascular disease (CVD) data can be sparse in low- and middle-income countries beyond urban centers. Despite this urban bias, CVD registries from the poorest countries have long revealed a predominance of nonatherosclerotic stroke, hypertensive heart disease, nonischemic and Chagas cardiomyopathies, rheumatic heart disease, and congenital heart anomalies, among others. Ischemic heart disease has been relatively uncommon. Here, we summarize what is known about the epidemiology of CVDs among the world’s poorest people and evaluate the relevance of global targets for CVD control in this population. We assessed both primary data sources, and the 2013 Global Burden of Disease Study modeled estimates in the world’s 16 poorest countries where 62% of the population are among the poorest billion. We found that ischemic heart disease accounted for only 12% of the combined CVD and congenital heart anomaly disability-adjusted life years (DALYs) in the poorest countries, compared with 51% of DALYs in high-income countries. We found that as little as 53% of the combined CVD and congenital heart anomaly burden (1629/3049 DALYs per 100 000) was attributed to behavioral or metabolic risk factors in the poorest countries (eg, in Niger, 82% of the population among the poorest billion) compared with 85% of the combined CVD and congenital heart anomaly burden (4439/5199 DALYs) in high-income countries. Further, of the combined CVD and congenital heart anomaly burden, 34% was accrued in people under age 30 years in the poorest countries, while only 3% is accrued under age 30 years in high-income countries. We conclude although the current global targets for noncommunicable disease and CVD control will help diminish premature CVD death in the poorest populations, they are not sufficient. Specifically, the current framework (1) excludes deaths of people <30 years of age and deaths attributable to congenital heart anomalies, and (2) emphasizes interventions to prevent and treat conditions attributed to behavioral and metabolic risks factors. We recommend a complementary strategy for the poorest populations that targets premature death at younger ages, addresses environmental and infectious risks, and introduces broader integrated health system interventions, including cardiac surgery for congenital and rheumatic heart disease.

Access to Medications for Cardiovascular Diseases in Low- and Middle-Income Countries

Cardiovascular diseases (CVD) represent the highest burden of disease globally. Medicines are a critical intervention used to prevent and treat CVD. This review describes access to medication for CVD from a health system perspective and strategies that have been used to promote access, including providing medicines at lower cost, improving medication supply, ensuring medicine quality, promoting appropriate use, and managing intellectual property issues. Using key evidence in published and gray literature and systematic reviews, we summarize advances in access to cardiovascular medicines using the 5 health system dimensions of access: availability, affordability, accessibility, acceptability, and quality of medicines. There are multiple barriers to access of CVD medicines, particularly in low- and middle-income countries. Low availability of CVD medicines has been reported in public and private healthcare facilities. When patients lack insurance and pay out of pocket to purchase medicines, medicines can be unaffordable. Accessibility and acceptability are low for medicines used in secondary prevention; increasing use is positively related to country income. Fixed-dose combinations have shown a positive effect on adherence and intermediate outcome measures such as blood pressure and cholesterol. We have a new opportunity to improve access to CVD medicines by using strategies such as efficient procurement of low-cost, quality-assured generic medicines, development of fixed-dose combination medicines, and promotion of adherence through insurance schemes that waive copayment for long-term medications. Monitoring progress at all levels, institutional, regional, national, and international, is vital to identifying gaps in access and implementing adequate policies.

Descriptive epidemiology and short-term outcomes of heart failure hospitalisation in rural Haiti.

Objective There is increasing attention to cardiovascular diseases in low-income countries. However, little is known about heart failure (HF) in rural areas, where most of the populations in low-income countries live. We studied HF epidemiology, care delivery and outcomes in rural Haiti. Methods Among adults admitted with HF to a rural Haitian tertiary care hospital during a 12-month period (2013–2014), we studied the clinical characteristics and short-term outcomes including length of stay, inhospital death and outpatient follow-up rates. Results HF accounted for 392/1049 (37%) admissions involving 311 individuals; over half (60%) were women. Mean age was 58.8 (SD 16.2) years for men and 48.3 (SD 18.8) years for women; 76 (41%) women were <40 years of age. Median length of stay was 10 days (first and second quartiles 7, 17), and inhospital mortality was 12% (n=37). Ninety nine (36%) of the 274 who survived their primary hospitalisation followed-up at the hospitals outpatient clinic, and 18 (6.6%) were readmitted to the same hospital within 30 days postdischarge. Decreased known follow-up (p<0.01) and readmissions (p=0.03) were associated with increased distance between patient residence and hospital. Among the one-quarter (81) patients with echocardiograms, causes of HF included: non-ischaemic cardiomyopathy (64%), right HF (12%), hypertensive heart disease (7%) and rheumatic heart disease (5%). One-half of the women with cardiomyopathy by echocardiogram had peripartum cardiomyopathy. Conclusions HF is a common cause of hospitalisation in rural Haiti. Among diagnosed patients, HF is overwhelming due to non-atherosclerotic heart disease and particularly affects young adults. Implementing effective systems to improve HF diagnosis and linkage to essential outpatient care is needed to reduce long-term morbidity and mortality.

Cardiovascular Complications of HIV in Endemic Countries

Effective combination antiretroviral therapy (ART) has enabled human immunodeficiency virus (HIV) infection to evolve from a generally fatal condition to a manageable chronic disease. This transition began two decades ago in high-income countries and has more recently begun in lower income, HIV endemic countries (HIV-ECs). With this transition, there has been a concurrent shift in clinical and public health burden from AIDS-related complications and opportunistic infections to those associated with well-controlled HIV disease, including cardiovascular disease (CVD). In the current treatment era, traditional CVD risk factors and HIV-related factors both contribute to an elevated risk of myocardial infarction, stroke, heart failure, and arrhythmias. In HIV-ECs, the high prevalence of persons living with HIV and growing prevalence of CVD risk factors will contribute to a growing epidemic of HIV-associated CVD. In this review, we discuss the epidemiology and pathophysiology of cardiovascular complications of HIV and the resultant implications for public health efforts in HIV-ECs.

Rheumatic Heart Disease: The Unfinished Global Agenda

Primarily affecting the young, rheumatic heart disease (RHD) is a neglected chronic disease commonly causing premature morbidity and mortality among the global poor. Standard clinical prevention and treatment is based on studies from the early antimicrobial era, as research investment halted soon after the virtual eradication of the disease from developed countries. The emergence of new global data on disease burden, new technologies, and a global health equity platform have revitalized interest and investment in RHD. This review surveys past and current evidence for standard RHD diagnosis and treatment, highlighting gaps in knowledge.

Global Health and Cardiovascular Disease

1217 The epidemic of noncommunicable diseases, including cardiovascular diseases (CVD), is the largest the world has ever known. In 2011, global heads of state joined together at the United Nations High Level Meeting to focus on noncommunicable diseases – the first time the United Nations focused on a health issue since the HIV/AIDS epidemic in 2001. We are faced with the ambitious target of reducing premature mortality from noncommunicable diseases by 25% by 2025. In our increasingly interconnected world, we must learn from challenges, celebrate successes, and share strategies in our fight against noncommunicable diseases. Starting with this issue of Circulation, international health leaders will share their insights on the global burden of cardiovascular disease from different perspectives. Within this 12-article thematic review series, authors will describe critical elements relating to the global burden of CVD from several perspectives to present an overview of the field. The first several articles will focus on the epidemiology of CVD risk factors and of CVDs – including those specific to people living in extreme poverty. Next, a series of articles will focus on healthcare delivery strategies in regions in which the American Heart Association is becoming increasingly engaged: Brazil, China, India, and Africa. The following several articles will evaluate issues of health systems such as resourceeffective strategies, access to essential CVD medicines, and the use of mobile health and other technologies. A global health ethics approach will be taken to evaluate the social determinants of cardiovascular diseases. To conclude the series, leaders will review the translation of the large body of evidence into effective, holistic, and forward-thinking international and national policies to drive action and reduce the global burden of CVDs. We are thankful to the authors of the Circulation global burden of CVD series for their comprehensive vision on addressing the worldwide CVD epidemic by articulating the past and current state, and providing recommendations for the future.The epidemic of noncommunicable diseases, including cardiovascular diseases (CVD), is the largest the world has ever known. In 2011, global heads of state joined together at the United Nations High Level Meeting to focus on noncommunicable diseases – the first time the United Nations focused on a health issue since the HIV/AIDS epidemic in 2001. We are faced with the ambitious target of reducing premature …

Treatment of non-communicable disease in rural resource-constrained settings: a comprehensive, integrated, nurse-led care model at public facilities in Rwanda

Abstract Background Low-income countries face a dual burden of endemic chronic non-communicable diseases (NCDs) and limited resources to implement control strategies. Access to services is even more challenging for patients in countries like Rwanda, where more than 80% of the population reside in rural areas, and there is fewer than one health care provider per 1000 people. Many studies of NCD care delivery models in low-income countries are limited to simple conditions or focus on a single disease. Since 2007, Partners in Health/Inshuti Mu Buzima (PIH/IMB) has been supporting delivery of NCD services at Ministry of Health facilities. Here we describe the model implemented and baseline characteristics of patients served. Methods Comprehensive NCD services are provided by nurses to patients with an array of complex conditions including heart failure, chronic cancer pain, hypertension, diabetes, and chronic respiratory diseases on disease-specific clinic days. Nurses receive training and longitudinal mentorship from specialist physicians and use reference-standardised diagnosis and treatment protocols. Point-of-care diagnostics are used, such as haemoglobin A1c for patients with diabetes and coagulation testing for patients on warfarin after cardiac valve surgery. Nurses are also able to perform simplified echocardiography to inform initial management of heart failure. Group education sessions and socioeconomic supports are also offered to patients. District hospital nurses serve as mentors for health centre nurses. Community health workers provide support to high-risk patients. Clinical information is documented in structured forms that are compiled in individual patient charts, and entered in an electronic medical records system. These programmes are integrated within MOH facilities and most clinicians are MOH employees. Findings At Sept 30, 2014, three district hospitals and seven health centres have implemented PIH/IMB-supported NCD programmes. 3367 patients have been enrolled, of whom 67% are female (mean age 48·1 years [SD 19·8]). Disease categories, in descending order of predominance, are: hypertension (30%), chronic respiratory disease (26%), heart failure (26%), and diabetes (16%). A small proportion (2·5%) of patients are HIV positive and 1% have more than one NCD diagnosis. More than 80% (3014) of patients live in rural districts, and of these more than 60% of those with documented occupation (683 out of total documented 1112) are subsistence farmers. Interpretation An integrated, nurse-led NCD care model has been effectively implemented in Rwanda, providing comprehensive longitudinal care embedded within the public health system in a rural resource-constrained setting. That so many patients have been treated highlights the NCD needs in rural poor populations. Positive outcomes have been described previously for heart failure, and outcomes assessments for diabetes, post-cardiac surgery, and hypertension are underway. The experience from these facilities has contributed to ongoing scale-up of district level NCD services throughout Rwanda. Funding Ministry of Health, Rwanda, Partners in Health /Inshuti Mu Buzima (PIH / IMB), Medtronic Foundation.

Understanding the Etiology of Heart Failure among the Rural Poor in Sub-Saharan Africa: a 10-year Experience from District Hospitals in Rwanda

BACKGROUND Heart failure is a significant cause of morbidity and mortality in sub-Saharan Africa. Our understanding of the heart failure burden in this region has been limited mainly to registries from urban referral centers. Starting in 2006, a nurse-driven strategy was initiated to provide echocardiography and decentralized heart failure care within noncommunicable disease (NCD) clinics in rural district hospitals in Rwanda. METHODS AND RESULTS We conducted a retrospective review of patients with cardiologist-confirmed heart failure treated at 3 district hospital NCD clinics in Rwanda from 2006 to 2017 to determine patient clinical characteristics and disease distribution. Over 10 years, 719 patients with confirmed heart failure were identified. Median age was 27 years overall, and 42 years in adults. Thirty-six percent were children (age <18 years), 68% were female, and 78% of adults were farmers. At entry, 39% were in New York Heart Association functional class III-IV. Among children, congenital heart disease (52%) and rheumatic heart disease (36%) were most common. In adults, cardiomyopathy (40%), rheumatic heart disease (27%), and hypertensive heart disease (13%) were most common. No patients were diagnosed with ischemic cardiomyopathy. CONCLUSIONS The results of the largest single-country heart failure cohort from rural sub-Saharan Africa demonstrate a persistent burden of rheumatic disease and nonischemic cardiomyopathies.

Outcomes for patients with rheumatic heart disease after cardiac surgery followed at rural district hospitals in Rwanda

Background In sub-Saharan Africa, continued clinical follow-up, after cardiac surgery, is only available at urban referral centres. We implemented a decentralised, integrated care model to provide longitudinal care for patients with advanced rheumatic heart disease (RHD) at district hospitals in rural Rwanda before and after heart surgery. Methods We collected data from charts at non-communicable disease (NCD) clinics at three rural district hospitals in Rwanda to describe the outcomes of 54 patients with RHD who received cardiac valve surgery during 2007–2015. Results The majority of patients were adults (46/54; 85%), and 74% were females. The median age at the time of surgery was 22 years in adults and 11 years in children. Advanced symptoms—New York Heart Association class III or IV—were present in 83% before surgery and only 4% afterwards. The mitral valve was the most common valve requiring surgery. Valvular surgery consisted mostly of a single valve (56%) and double valve (41%). Patients were followed for a median of 3 years (range 0.2–7.9) during which 7.4% of them died; all deaths were patients who had undergone bioprosthetic valve replacement. For patients with mechanical valves, anticoagulation was checked at 96% of visits. There were no known bleeding or thrombotic events requiring hospitalisation. Conclusion Outcomes of postoperative patients with RHD tracked in rural Rwanda health facilities were generally good. With appropriate training and supervision, it is feasible to safely decentralise follow-up of patients with RHD to nurse-led specialised NCD clinics after cardiac surgery.